Provider Demographics
NPI:1710023601
Name:EIDGAH, MAHYAR (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHYAR
Middle Name:
Last Name:EIDGAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4201
Mailing Address - Country:US
Mailing Address - Phone:212-979-4204
Mailing Address - Fax:212-979-4415
Practice Address - Street 1:310 E 14TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4201
Practice Address - Country:US
Practice Address - Phone:212-979-4204
Practice Address - Fax:212-979-4415
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232944207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02599177Medicaid
NY02599177Medicaid
NY5430B1Medicare PIN